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Auto Accident Settlement.com
C/O
Attorney Richard M. Callahan
2 Pierro Terrace
Swampscott, Massachusetts, 01907.
(866) 529-8373

Free Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
Time of Accident:
City where accident occured:	*
State where accident occured:	*

Estimated medical expenses (bills) to date:

Approximate money lost due to injury:
Did you go to the doctor?	Yes No
Did you go to the hospital?	Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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understanding the facts of your case?

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Please tell us exactly what terms you typed into the
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AutoAccidentSettlement.com is sponsored by: Attorney Donald Grady, Jr* Sheff Law Offices, P.C. 10 Tremont Street, Boston, Massachusetts, 01908. Call us toll-free at (866) 529-8373. *Admitted to practice in New York and Massachusetts. Copyright � 2003 - 2009 AutoAccidentSettlement.com. All Rights Reserved.